MIPS Improvement Activities Performance Category

MIPS Improvement Activities (2024)

The MIPS Improvement Activities performance category rewards eligible clinicians (ECs) and groups for engaging in clinical practice improvement activities such as care coordination, beneficiary engagement, and patient safety. Improvement Activities account for 15% of the total MIPS score in performance year 2024. Most anesthesiologists and their groups will attest to the MIPS Improvement Activities category via a Qualified Registry, a Qualified Clinical Data Registry, or though the Quality Payment Program website.

CMS has finalized a list of more than 100 activities for the 2024 performance year. AQI NACOR supports attestation for more than fifty anesthesia-related improvement activities. The list of MIPS Improvement Activities and their data validation requirements are available via the Quality Payment Program Resource Library.

Please make sure to check improvement activities requirements and descriptions each year as CMS adds, deletes, and amends improvement activities each year. 

If you choose to report a MIPS Value Pathway (MVP), you MUST choose from the list of improvement activities available in the MVP. 

Each individual improvement activity is assigned a weight of either medium or high. Medium weighted activities receive 10 points and high weighted activities receive 20 points. To receive full credit for the performance category, eligible clinicians and groups must receive a score of 40 points. Small practices, rural practices, practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS eligible clinicians will have their medium weighted activities count for 20 points and their high weighted activities count for 40 points. They will still be required to reach 40 points to receive full credit for this component.

For groups, CMS requires 50% of the group’s National Provider Identifier (NPI) clinicians to perform the same improvement activity during any continuous 90-day period within the same performance year.

Eligible clinicians and groups are subject to auditing from their data/registry vendor or CMS for up to six years AFTER the performance year. Eligible clinicians and their groups should retain documentation of their improvement activity performance.

MIPS Improvement Activities (2023)

The MIPS Improvement Activities performance category rewards eligible clinicians (ECs) and groups for engaging in clinical practice improvement activities such as care coordination, beneficiary engagement, and patient safety. Improvement Activities account for 15% of the total MIPS score in performance year 2023. Most anesthesiologists and their groups will attest to the MIPS Improvement Activities category via a Qualified Registry, a Qualified Clinical Data Registry, or though the Quality Payment Program website.

CMS has finalized a list of more than 100 activities for the 2023 performance year. AQI NACOR supports attestation for more than fifty anesthesia-related improvement activities. The list of MIPS Improvement Activities and their data validation requirements are available via the Quality Payment Program Resource Library.

If you choose to report a MIPS Value Pathway (MVP), you MUST choose from the list of improvement activities available in the MVP. 

Each individual improvement activity is assigned a weight of either medium or high. Medium weighted activities receive 10 points and high weighted activities receive 20 points. To receive full credit for the performance category, eligible clinicians and groups must receive a score of 40 points. Small practices, rural practices, practices located in geographic health professional shortage areas (HPSAs), and non-patient facing MIPS eligible clinicians will have their medium weighted activities count for 20 points and their high weighted activities count for 40 points. They will still be required to reach 40 points to receive full credit for this component.

For groups, CMS requires 50% of the group’s National Provider Identifier (NPI) clinicians to perform the same improvement activity during any continuous 90-day period within the same performance year.

Eligible clinicians and groups are subject to auditing from their data/registry vendor or CMS for up to six years AFTER the performance year. Eligible clinicians and their groups should retain documentation of their improvement activity performance.